Fill - Free fillable VIII. Forms A. Application for Employment VIII-1 (Baldwin County Commission) PDF form

VIII. Forms

Baldwin County Employee Handbook - Approved 4/2/2013

Updated 10/21/2014

Updated 12/20/2016

VIII. Forms

The following forms have been approved for use by the Baldwin County Commission:

A. Application for Employment VIII-1

B. Pre-Employment Physical and Drug Screen Waiver VIII-3

C. Authorization For Background Investigation and Release of Information VIII-4

D. Personnel Appraisal Form VIII-5

E. ADA Reasonable Accommodation Request Form VIII-8

F. Employee Counseling Form VIII-9

G. Notice of Disciplinary Action Form VIII-10

H. Grievance Appeal Form VIII-11

I. Leave Request Form VIII-12

J. Temporary Transitional Duty Agreement VIII-13

K. Medical Treatment Waiver VIII-14

L. Property Damage/Collision/Injury/Illness Investigation Report VIII-15

M. Accident Injury Witness Report VIII-20

N. Last Chance Assistance Agreement VIII-21

BALDWIN COUNTY COMMISSION

APPLICATION FOR EMPLOYMENT

Baldwin County Commission is an equal opportunity employer. It is our policy to abide by all federal

and state laws prohibiting employment discrimination solely on the basis of a person’s race, color, creed, national origin,

religion, age (over 40), sex, marital status, or physical or mental disability, except where a reasonable, bona fide occupational

qualification exists.

GENERAL INFORMATION

Name (Last)

(First)

(Middle Initial)

Home Telephone

( ) -

Address (Mailing Address)

(City)

(State)

(Zip)

Other Telephone

( ) -

E-Mail Address

Are you legally entitled to work in the U.S.?

☐

Yes

☐

No

POSITION

Position Desired

Are you able to perform the essential functions of the job you are applying for, with or without reasonable accommodation?

☐

Yes

☐

No

Salary/Hourly Rate Desired

Date Available

EDUCATION

High School Graduate or General Education (GED) Test Passed? ☐ Yes ☐ No If no, list the highest grade completed.

College, Business School, Military (Most recent first)

Name and Location

Dates Attended

Month/Year

Credits Earned Graduate

Degree &

Year

Major or Subject

Quarterly/

Semester

Hours

Other

(Specify)

From:

☐ Yes

☐

No

To:

From:

☐ Yes

☐

No

To:

From:

☐ Yes

☐

No

To:

From:

☐ Yes

☐

No

To:

Occupational License, Certificate or Registration

Number

Where Issued

Expiration Date

Occupational License, Certificate or Registration

Number

Where Issued

Expiration Date

Occupational License, Certificate or Registration

Number

Where Issued

Expiration Date

Valid Driver’s License

☐

Yes

☐

No

Commercial Driver’s License

☐

Yes

☐

No

Commercial Driver’s License Class

☐

Class A

☐

Class B

☐

Class C

Endorsements:

Languages Read, Written or Spoken Fluently Other Than English

VETERAN INFORMATION (Most recent)

Branch of Service

Date of Entry

Date of Discharge

SPECIAL SKILLS (List all pertinent skills and equipment that you can operate)

VIII-1

WORK EXPERIENCE (Most recent first)

Employer

Telephone Number

From (Month/Year)

Address (Mailing)

(City)

(State)

(Zip)

To (Month/Year)

Job Title

Reason for Leaving

Hours Worked Per

Week

Specific Job Duties

Last Salary

Supervisor

May We Contact This

Employer?

☐ Yes ☐ No

Employer

Telephone Number

From (Month/Year)

Address (Mailing)

(City)

(State)

(Zip)

To (Month/Year)

Job Title

Reason for Leaving

Hours Worked Per

Week

Specific Job Duties

Last Salary

Supervisor

May We Contact This

Employer?

☐ Yes ☐ No

Employer

Telephone Number

From (Month/Year)

Address (Mailing)

(City)

(State)

(Zip)

To (Month/Year)

Job Title

Reason for Leaving

Hours Worked Per

Week

Specific Job Duties

Last Salary

Supervisor

May We Contact This

Employer?

☐ Yes ☒ No

Employer

Telephone Number

From (Month/Year)

Address (Mailing)

(City)

(State)

(Zip)

To (Month/Year)

Job Title

Reason for Leaving

Hours Worked Per

Week

Specific Job Duties

Last Salary

Supervisor

May We Contact This

Employer?

☐ Yes ☐ No

I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my

knowledge. I also agree that falsified information or significant omissions may disqualify me from further consideration for employment and

may be considered justification for dismissal if discovered at a later date.

If employed by the Baldwin County Commission, I agree to and review and abide by the Alabama Code of Ethics, Section 36-23-1 thru 20,

Ala.

Code

1975 , as the same may be amended, and policies and procedures of the Baldwin County Commission, which includes the Baldwin

County Commission’s Anti-Harassment policy. I further understand that while in a probationary statues, my employment can be terminated,

with or without cause or notice, at any time, at the discretion of the Baldwin County Commission or myself. I further understand that no

representative of the Baldwin County Commission other than the Personnel Director, Appointing Authority or Appointed Department Head

has any authority to enter into any agreement, oral or written, on behalf of the Baldwin County Commission for a term of employment or to

make any assurance or promise of continued employment, subject to approval by the Baldwin County Commission.

If employed by the Baldwin County Commission, I understand and agree that I may be required to take a pre-employment drug and alcohol

screening test. I also consent to the release of the test results to the Baldwin County Commission for its use, and I understand that any

positive drug or alcohol result may preclude my employment. The Baldwin County Commission may conduct a pre-employment background

check, including, but not limited to, criminal, drivers’ license, and reference checks.

By typing or signing my name in the following space, I certify the above statements to be true and correct, to the best of my knowledge, and I

agree that this information can be used for the purpose of processing my employment application and information.

Signature of Applicant____________________________________________ Date___________________

VIII-2

NEW HIRE CONSENT FORM FOR SUBSTANCE ABUSE SCREENING TEST

PRE-EMPLOYMENT PHYSICAL EXAM

It is the policy of Baldwin County that all applicants, who either are likely to be offered employment or who have been extended an

offer of employment, undergo a routine pre-employment physical exam.

*H

iring decisions may be based upon the results of medical tests conducted as part of this examination process.

STATEMENT OF COUNTY POLICY

It is the policy of the County to maintain a safe work environment conducive to effective business operations.

The County requires that personnel and operating practices be consistent with the highest standards of health and safety.

Selling, purchasing, using, possessing, or being under the influence of any illegal substance, without medical

authorization, during the work day, on the County premises or while conducting county business is inconsistent with the

County’s business interests and will be grounds for disciplinary action, up to and including termination.

APPLICANT CONSENT

Re: Authorization to Perform the Urine and/or Breath Testing:

I, __________________________________________, understand that by accepting employment with Baldwin

County Commission, I agree willingly to participate in the urine and/or breath testing program under the provisions set

forth on the alcohol and controlled substance abuse policy.

I

understand that if I decline to sign this consent and thereby decline to take the test, the medical examination will

not be completed, and my employment offer will be rescinded.

If the test is confirmed as positive, the results will be reported to the Personnel Department. An exception will be

made for the use of legally prescribed medications taken under the direction of a physician.

Re: Authorization to Perform the Medical Examinations:

I also hereby authorize and give my consent to a qualified medical representative and/or physician to conduct the

above-mentioned physical examination to also include, without limitation, a drug screening urine analysis all as part of the

pre-employment requirements of Baldwin County.

I

understand that, submitting to such examinations does not guarantee employment with Baldwin County.

I

understand that if I decline to sign this consent form and further decline to take the physical exam as has been

requested, then the medical examination will not be completed, and an offer of employment will either not be extended or

will be withdrawn, if previously made.

Re: Authorization to Release Sensitive Medical Information:

I further authorize Baldwin County’s designated physician, medical personnel or testing facility to release to

Baldwin County any and all results of such physical examination and testing along with any relevant medical information.

Signature:________________________________ Print Name:_______________________________

Witness:__________________________________ Date:__________________________

VIII-3

AUTHORIZATION FOR BACKGROUND INVESTIGATION AND RELEASE OF INFORMATION

Following a conditional offer of employment, and as part of the hiring and employment process and pursuant to its

policies, the Baldwin County Commission (the “County”) will perform a public record information search and/or an

investigative consumer report search on individuals seeking employment with the County. Such individuals will be

required to maintain satisfactory criminal history records, pertinent to his or her position, as a condition of

employment.

I

,_____________________________, hereby authorize and give consent for the Baldwin County Commission to

obtain information pertaining to myself. This includes the following:

• C

riminal Background Records/Information

• Sex Offender Registry Information

• Social Security Number Verification

• Drivers License Currency and Check

• Driving Record

• Credit History – if applicable to position

• Other Background Information Deemed Necessary by the County.

I understand that this information will be used, in part to determine my eligibility for employment. The records being

checked are covered by the Fair Credit Reporting Act (FCRA). The FCRA gives me specific rights in dealing with

agencies that provide these reports to the County. Before making any adverse employment action which is based on

the information received from a criminal background check, the County will notify me in writing and will provide me

with a copy of the report and “A Summary of Your Rights Under The Fair Credit Reporting Act”. If I am denied

employment, either wholly or partly because of information contained in resulting reports, a disclosure will be made

to me of the name and address of the consumer reporting agency making such report.

B

y signing this form, I authorize the Baldwin County Commission to periodically access and review state and federal

criminal history records and make reasonable efforts to determine where I have been convicted of, or are pending

indictment for, a crime that bears upon my fitness to be employed.

______________________________ ____________________________________

Date Name of Applicant (Print)

____________________________________

Signature of Applicant

____________________________________

Date of Birth

____________________________________

Social Security Number

____________________________________

Driver’s Licenses # / Expiration

____________________________________

Position Applied for

VIII-4

BALDWIN COUNTY COMMISSION

PERSONNEL APPRAISAL FORM

Name________________________________________ Evaluation Month____________________________

Employee Grade/

Number ___________ Title_____________________ Step________ Department_____________________

Employee performance based on the following scale:

1=UNACCEPTABLE

Employees performance on a specific job duty or in an overall rating does not meet the required standards of performance for

the position

.

2=NEEDS IMPROVEMENT

Employee that scores a two (2) in any single category or in an overall rating is not fulfilling the responsibilities of the job and

needs to be counseled [with a written improvement plan] as to what actions he/she must take to bring their performance up to

acceptable standards

.

3=MEETS STANDARDS

Rating indicates that an employee has performed at a level that meets the requirements of the specific duties set forth in their

job description in addition to the specific criteria listed on the performance review form as it relates to attendance, work habits

and personal traits

.

4=EXCEEDS STANDARDS

Rating indicates that an individual is performing at a level that is above the expected standards of their position which

includes, but is not limited to, taking extra initiative, demonstrating an exemplary attitude, demonstrating an ability to think

and perform beyond what the job duties and responsibilities call for, willing to take on additional tasks and assignments as

requested

.

5=EXCEPTIONAL

Rating includes all of the performance achievements specified in the exceeds standard category, with the inclusion of

consistency in performance day in and day out at the elevated level.

Category

Rating

Comments

Technical Skills-

Effectiveness with which the employee

applies job knowledge and skill to job

assignments.

Job Knowledge

Analyzes Problems

Provides Suggestions for Work Improvement

Employs Tools of the Job Competently

Follows Proper Safety Procedures

[ ] 1

[ ] 2

[ ] 3

[ ] 4

[ ] 5

Quality of Work-

Manner in which the employee

completes job assignments.

Accuracy or Precision

Thoroughness/Neatness/Reliability

Responsiveness to Requests

Follow-Through/Follow-Up

Judgment/Decision Making

[ ] 1

[ ] 2

[ ] 3

[ ] 4

[ ] 5

VIII-5

Interpersonal Skills-

Effectiveness of the employee’s

interactions with others and as a

team participant.

With Co-workers

With Supervisors

With Other Staff/Community

Team Contributions

Commitment to Team Success

[ ] 1

[ ] 2

[ ] 3

[ ] 4

[ ] 5

Approach to Work-

Characteristics the employee

demonstrates while performing job

assignments

Actively Seeks Ways to Streamline

Processes, Open to New Ideas and

Approaches, Shows Initiative

Planning and Organization-Flexible/Adaptable

Follows Instructions

Seeks Additional Training and Development

Attendance

[ ] 1

[ ] 2

[ ] 3

[ ] 4

[ ] 5

Quantity of Work-

Employee’s success in producing the

required amount of work.

Priority Setting

Amount of Work Completed

Work Completed on Schedule

[ ] 1

[ ] 2

[ ] 3

[ ] 4

[ ] 5

Supervisory Skills-

Applies only to employee who is a

Manager or Supervisor

Trains and Develops Staff

Properly Aligns Responsibility,

Accountability, Authority

Handles Performance Problems with Staff

Instills Pride in Performance, Service,

Innovation, and Quality

Welcomes Constructive Criticism

Sets Specific Goals for Staff

[ ] 1

[ ] 2

[ ] 3

[ ] 4

[ ] 5

Personnel Use Only:

Scoring:

Section 1 - _____

Section 2 - _____

Section 3 - _____

Section 4 - _____

Section 5 - _____

Section 6 - _____

Merit Score - _______

VIII-6

Comments:

Goals:

Employee Comments:

By signing below you agree that you have completely read and discussed your appraisal with your

supervisor and have been given a copy of this evaluation. You have been given an opportunity to provide

written comments to anything in this appraisal to be included in your personnel records. By signing this

appraisal, it does not mean that you agree with this evaluation.

Employee Signature:_____________________________________ Date:_____________________________

Rater Signature:_________________________________________ Date:_____________________________

Dept Head Signature:_____________________________________ Date:_____________________________

Co. Administrator Signature:_______________________________ Date_____________________________

Public Official Signature: __________________________________ Date_____________________________

VIII-7

Americans with Disabilities Act of 1990 (ADA)

REASONABLE ACCOMMODATION REQUEST FORM

A. Questions to clarify accommodation requested.

What specific accommodation are you requesting?

If you are not sure what accommodation is needed, do you have any suggestions

about what options we can explore? If yes, please explain.

Yes  No 

Is your accommodation request time sensitive? If yes, please explain.

Yes 

No 

B. Questions to document the reason for accommodation request.

What, if any, job function are you having difficulty performing?

What limitation is interfering with your ability to perform your job or access an employment benefit?

Have you had any accommodations in the past for this same limitation? Yes  No 

If yes, how effective were they?

If you are requesting a specific accommodation, how will that accommodation assist you?

C. Other.

Please provide any additional information that might be useful in processing your accommodation request:

______________________________ _______________

Signature Date

Re

turn this form to the Personnel Director

VIII-8

BALDWIN COUNTY COMMISSION

EMPLOYEE COUNSELING

Employee Name:_______________________________ Date of Notice:_____________________________

Employee Number:_____________________________ Department:_______________________________

Details Regarding the Issue:

__________________________________________________________________________________________

How the Issue Affects the Work Group:

__________________________________________________________________________________________

Causes of the Issue:

__________________________________________________________________________________________

Solutions to the Issue:

__________________________________________________________________________________________

Actions to be Taken to Correct the Issue: Employee Suggestions

__________________________________________________________________________________________

Follow-Up Date to Discuss Improvement:

__________________________________________________________________________________________

SIGNING BELOW INDICATES ACKNOWLEDGEMEENT OF THE ABOVE CONVERSATION.

Employee Signature______________________________________________ Date____________________

Supervisor Signature______________________________________________ Date____________________

Department Head Signature________________________________________ Date____________________

Elected Official Signature__________________________________________ Date____________________

Original: Personnel Copy: Department and Employee

VIII-9

BALDWIN COUNTY COMMISSION

NOTICE OF DISCIPLINARY ACTION

Employee Name:_______________________________ Date of Notice:_____________________________

Employee Number:_____________________________ Department:_______________________________

Type of Disciplinary: (Employees have the right to appeal a suspension without pay, termination or involuntary demotion. The employee has one (1) working day to

request, in writing, a hearing. The employee is placed on administrative leave with pay for the one (1) working day in order to decide on the pre-disciplinary hearing. If

the employee does not request a hearing, the proposed discipline will become effective at the end of the one (1) working day period.)

☐ Written ☐ Suspension: From__________ To__________

Type of Problem or Violation:

☐ Absenteeism ☐ Poor Work Performance Violation Date:_____________________________

☐ Tardiness ☐ Safety/Carelessness Violation Time:_____________________________

☐ Insubordination ☐ Violation of Company Policy Place violation Occurred:_____________________

☐ Other:____________________________________

____________________________________

Details of Occurrence: (Use additional paper if necessary.)

__________________________________________________________________________________________

Expected Improvement: (Use additional paper if necessary. Include a clear statement as to the consequences of failing to improve.)

__________________________________________________________________________________________

Employee’s Statement: (Use additional paper if necessary.)

__________________________________________________________________________________________

List All Previous Warnings or Suspensions (when and by whom):

Previous Warning: 1

st

Warning 2

nd

Warning 3

rd

Warning

Date:_______________________ Date:_______________________ Date:_______________________

Written:_______________________ Written:_______________________ Written:_______________________

Suspension:_______________________ Suspension:_______________________

Suspension:_______________________

I ACKNOWLEDGE RECEIPT OF THIS DISCIPLINARY ACTION AND THAT ITS CONTENTS HAVE BEEN

DISCUSSED WITH ME. I UNDERSTAND THAT MY SIGNATURE DOES NOT NECESSARILY INDICATE

AGREEMENT.

Employee Signature______________________________________________ Date____________________

Supervisor Signature______________________________________________ Date____________________

Department Head Signature________________________________________ Date____________________

Elected Official Signature__________________________________________ Date____________________

Personnel Representative___________________________________________ Date____________________

Original: Personnel Copy: Department and Employee

VIII-10

Ms. Andrea Rider Baldwin County Personnel Board

Personnel Director Bay Minette, Alabama 36507

On this date, ______________________________, I hereby appeal to the Personnel

Board my:

______ Dismissal

______ Suspension

______ Demotion

I, ____ admit the charge/charges brought against me.

____ deny the charge/charges brought against me.

____ Other ____________________________________________________________

The disciplinary action taken against me should not become effective because of the

following reasons:

______ The action is too severe

______ I am not guilty of the charges brought against me

______ Other_______________________________________________________

The relief I seek is: ________________________________________________________

______________________________________________________________________________

___________________________________

Signature

___________________________________

Department/Classification

___________________________________

Mailing Address (Home)

___________________________________

City, State, Zip Telephone

Please attach any previous discussions by supervisor or department head that relates to this

request.

VIII-11

BALDWIN COUNTY COMMISSION

LEAVE REQUEST

Name Date

Department Employee Number

Date(s) Requested

Type of Leave Requested:

Annual Leave

Sick Leave

Personal Leave

Other - Specify

It is requested that you provide an explanation for the use of all sick leave.

Employee’s Signature

Supervisor’s Signature

Department Head’s Signature

VIII-12

Baldwin County Personnel Department

Acknowledgement of Temporary Transitional Duty Assignment

I have been advised of the physical limitations outlined by the attending physician/medical provider and

understand my work restrictions. I further understand that it is my responsibility not to violate these

restrictions without specific medical authorization. I further agree that if management asks that I

perform duties, which would violate these work restrictions, I will immediately advise my assigned

supervisor and/or other management, if necessary, of my physical limitations concerning the requested

duties. I understand that these accommodations are temporary and that they may be canceled at any time

by the Baldwin County Commission or their designated representative.

I HAVE RECEIVED A COPY OF THE TRANSITIONAL DUTY POLICY, AND AS A

PARTICIPANT IN THIS PROGRAM, I WILL ADHERE TO ALL POLICIES AND

PROCEDURES.

Restrictions:

This is in effect until the next doctor’s appointment on: ______________________________________

______________________________________ __________________________________

Injured Employee Signature / Date Print Injured Employee Name

_

______________________________________

Direct Supervisor Signature / Date

_________

___________________

Safety Coordinator Signature/ Date

____________________________

Risk Manager Signature / Date

________

____________________

Personnel Director Signature / Date

_________

_________________________

Appointed Dept. Director Signature / Date

VIII-13

Baldwin County Personnel Department

Medical Treatment Waiver

Baldwin County Commission is concerned with every employee’s well-being. In the event you elect not to seek

medical attention for this alleged Worker’s Compensation Injury, we need to document that the Baldwin County

Commission has not influenced, in any way, your decision to not seek treatment.

Employee Name: ________________________________________________________________

Date of Injury: __________________________________________________________________

Description of Accident: __________________________________________________________

______________________________________________________________________________

Description of Injury: ____________________________________________________________

______________________________________________________________________________

My signature confirms that I have voluntarily waived medical care due to the injury indicated above. Should it

later be determined that I require medical care, I will consult with my Supervisor prior to seeking treatment for

this injury, unless emergency treatment is required.

_____________________________________________ _____________________________________________

Direct Supervisor Signature / Date Employee Signature / Date

_

____________________________________________ _____________________________

________________

Safety Coordinator Signature/ Date Risk Manager Signature / Date

______________________________________________ _____________________________________________

A

ppointed Dept. Director Signature / Date Personnel Director Signature / Date

VIII-14

Baldwin County Personnel Department

Property Damage / Collision / Injury / Illness Investigation Report

*THIS FORM IS TO BE FILLED OUT IN A TEAM EFFORT BY A SAFETY REPRESENTATIVE, SUPERVISOR,

AND RELEVANT PERSONNEL AS NEEDED.*

**Please complete only the sections that are applicable to the type of report that you are investigating**

***Please X the type of report being completed. (If more than one please X accordingly.)***

___Property Damage ___Collision ___Injury ___Illness

1.) Employee’s Full Name: ____________________________________

8.) Employee Job Title:_________________________

2.) Today’s Date: ___________________________________________

9.) Department: _______________________________

3.) Direct Supervisor’s Name: _________________________________

10.) Full or Part Time Employee: __________________

4.) Location of Incident:______________________________________

11.) Supv. Phone Number: (___)___________________

5.) Date Incident Occurred: ___________________________________

12.) Time of Incident____________________________

6.) Date First Reported to Supervisor by Employee: ________________

13.) Time First Reported: ________________________

7.) Days Lost at Time of Investigation:___________________________

14.) Employee Phone Number: (___)_______________

15.) Was medical treatment provided?

YES □

NO □

16.) Was the incident a violation of the Personnel Handbook?

YES □

NO □

17.) Was proper procedure being followed by the employee?

YES □

NO □

18.) Was employee instructed in safe operating procedures?

YES □

NO □

19.) Prior discipline for safety procedures?

YES □

NO □

20.) Was employee performing his/her regular duty at the time of injury?

YES □

NO □

If the answer is no, what were the employee’s duties at the time of the injury?

21.) Describe the Equipment, Object or Substance causing incident:

22.) Was the employee provided with the proper safety equipment to safely perform his/her job?

23.) Is this related to manual material handling? (Is so, please describe.)

24.) Describe the incident in detail:

25.) Please describe employee injury if applicable:

26.) When did you (the supervisor) first learn of the employee’s incident?

27.) Names of Witness(es):

Place Employee First & Last Initial Here____

VIII-15

28.) Doctor Visit Required: YES NO 29.) Drug Screen Required: YES NO 30.) Drug Screen Performed: YES NO

31.) Contributing Causes (Unsafe acts/conditions contributing to the injury/illness (X all that apply).)

Caught Between

Pushing

Lockout / Tagout

Faulty Equipment

Caught In

Pulling

Confined Space Entry

Electrical

Caught Under

Lifting

Manual Material

Handling

Motor Vehicle

Falls Against

Struck By

Overexertion

Chemical

Falls From Elevation

Stepped In

Temperature Extremes

Housekeeping

Falls Into

Stepped On

Occupational Health

Hazards

Shortcuts / Carelessness

Falls On The Same Level

Stepped To

Noise

Improper Equipment Use

Jumped On

Stepped From

Video Display Terminal

Miscellaneous

Jumped To

Repetitive Motion

Lighting

Uncontrolled Force

Jumped From

Vibration

Guarding

Prior Injury

32.) Could the incident recur:

Often □

Occasionally □

Rarely □

If so, would it possibly be:

Very Serious □

Serious □

Minor □

33.) Please list a valid mailing address for the employee:

34.) Was the proper internal reporting procedure followed by the Injured Employee? YES NO

35.) Was the proper internal reporting procedure followed by the Employee’s Supervisor? YES NO UNDETERMINED

36.) Photos taken at scene: YES NO If photos taken, who took them:

37.) Did incident involve an Authorized Motor Vehicle, Off Road Equipment, or Both? (Please explain).

38.) Was Authorized Motor Vehicle or Off Road Equipment in motion or stopped at the time of the incident?

39.) Was Authorized Motor Vehicle or Off Road Equipment at an intersection: Yes No

40.) The Authorized Motor Vehicle or Off Road Equipment was: On Roadway or Off Roadway

41.) Environmental Conditions: (Please X all that apply)

Weather Surface Traffic Control Light # of Roadway Lanes

___Clear ___Dry ___Stop Sign ___Daylight ___2

___Cloudy ___Wet _ ___Yield Sign ___Dawn ___3

___Raining ___Icy ___Traffic Signal ___Dusk ___4

___Snowing ___Snow ___Flagman ___Unlighted Road ___5

___Foggy ___Uncontrolled ___Lighted Road ___6

___Other ___Other ___Other ___Other ____

Roadway Roadway Characteristics Unusual Road Conditions

___Divided ___Straight & Level ___Holes/Deep Ruts

___Undivided ___Straight & Grade ___Obstruction in Road

___Asphalt ___Straight & Hillcrest ___Flooded

___Concrete ___Curve & Level ___Construction/Repair Zone

___Gravel ___Curve & Grade ___Reduced Road Width

___Dirt ___Curve & Hillcrest ___Other

___Other ___Other

42.) County Authorized Motor Vehicle or Off Road Equipment Information if applicable:

Vehicle Number: _______________ VIN Number: ______________________________

Year: ________________ Make/Model: ______________________________________________

Tag Number: __________________

# Of Occupants: __________ # Seated: __________ # Standing: ________ # Injured:__________

Was Vehicle Towed: Yes No By Whom: _____________________________________

Place Employee First & Last Initial Here____

VIII-16

43.) Type of Collision:

Other Vehicle Fixed Object Bicyclist Pedestrian Animal Train Off Road Equipment

44.) If a Non County Owned Vehicle was involved, please complete the following information:(If more than two vehicle, please use

an additional sheet for their information)

Nam

e of Driver_____________________________ Phone #___________________________

Address____________________________________________________________________

Date of Birth: ___________ Sex: M F Drivers Lic. #:_____________ Lic. State: ___________

# Of Occupants: ______Year:______ Color: _______ Make/Model: ________________________

VIN Number: _________________________ Tag Number:__________________ Tag State:_____

Was Vehicle Towed: Yes No By Whom: _____________________________________

Insurance Company: _____________________________________________________________

Owner of Vehicle (if Different from Driver):____________________________________________

Phone #:____________ Address: ___________________________________________________

45.) Damage Information: (County Equipment is V1 and other equipment is V2)

Ind

icate damage on County Vehicle (V1):

2 3 4 0 = None

9 = Top

Front 1 5 Rear 10 = Under carriage

11 = Totaled

8 7 6 12 = Other

Ind

icate damage on Other Vehicle (V2):

2 3 4 0 = None

9 = Top

Front 1 5 Rear 10 = Under carriage

11 = Totaled

8 7 6 12 = Other

46.) Pre-Incident Movement: (Please X all that apply)

V1

V2/OV

V1

V2/OV

Going Straight Ahead

Exiting Vehicle

Making Right Turn

Entering Vehicle

Making Right on Red

Slowing or Stopping

Making Left Turn

Stopped at Traffic

Making U Turn

Parked

Changing Lanes

Avoided Object in Road

Passing

Vehicle Lights On

Merging

Vehicle Lights Off

Backing

Emergency Flashers / Strobes

Lights Activated

Other

Left Turn Signal On

Vehicle was parked

Right Turn Signal Off

Posted Speed Limit Estimated Speed Direction of Travel

V1

= ___________MPH V1 = ___________MPH V1 = N S E W

V2 = ___________MPH V2 = ___________MPH V2 = N S E W

Place Employee First & Last Initial Here____

VIII-17

Pedestrian / Bicyclist Action

Crossing with signal

Crossing no signal or crosswalk

Crossing against signal

Crossing no signal or marked crosswalk

Going to/from stopped bus

Other

Collision Type

___Backing ___Merging ___Sideswipe

___Head-On ___Right Angle ___Passing

___Rear-ends Vehicle ___Vehicle Rear-ends Bus ___Sudden Stop

___Right Mirror ___Left Mirror ___Ran off Road

___Wheelchair Lift Operations ___Door Operation ___Other___________

Police Investigated: Yes No Police Department: ___________________________________

Officer Name (Badge #):_________________________Report Number: ____________________

Citation/ Arrest: ___None issued ___Operator 1 ___ Operator 2 ___Bicyclist ___Pedestrian

Riding/walking along highway with traffic

Riding/walking along highway against traffic

Emerging from in front/behind parked vehicle

Getting in/out of vehicle (Not Bus)

Pushing/working on vehicle

Working on roadway

47.) Collision Diagram

(A) Use solid line to show path of each vehicle before collision

(B) Use dotted line to show path of vehicle after collision.

48.) Please explain any other unsafe act(s) or hazardous condition(s) that could have contributed to this incident (give details):

49.) List any corrective action suggested, or any action to be taken: **NOTE** It is the overall responsibility, of the Appointed

Department Director to complete or deny Corrective Actions as suggested.

Place Employee First & Last Initial Here____

VIII-18

50.) Person and Position Title to whom corrective action was assigned:

51.) Date corrective action to be completed:

52.) Comments:

________________________________ _______________________________________

Direct Supervisor Signature / Date Injured Employee Signature / Date

___________

_____________________ _________________________ _______________________________________

Safety Coordinator Signature/ Date Risk Manager Signature / Date Personnel Director Signature / Date

_____________

_____________________ _______________________________________

Appointed Dept. Director Signature / Date County Commission Chairman Signature / Date

Place Employee First & Last Initial Here____

VIII-19

Baldwin County Personnel Department

Witness Incident/Injury Report

1. Witness Name

2. Employee Identification

3. Today’s Date

4. Injured Employee Name

5. Date of Injury

6. When did you first observe the incident/injury?

7. Where were you at the time?

8. In what part of the body did the injured employee say there was pain?

9. Did the injured employee continue to work despite the pain?

10. Has the injured employee ever mentioned this pain before?

11. Did you see anything strike the injured employee?

12. Did you see anyone slip or trip?

13. Was there a sudden stress or strain?

14. Describe anything unusual that happened or any other comments.

15. If lifting was involved, please describe the lifting procedure used.

16. List names of other witnesses.

17. Was the incident/injury immediately reported to a supervisor? (If so, who?)

18. In your own words, describe the incident/injury that you saw. Please give as many details as possible

and include where the incident occurred. You may provide a sketch as part of your explanation. Please use

the back or another sheet of paper if needed for your explanation.

P

lease complete this report before you leave the workplace and sign below.

____________________________________ ____________________________________

Safety Representative Signature / Date Witness Signature/ Date

**The witness to the incident should fill out this form. If more than one witness, please have each fill out a separate form.**

VIII-20

Last Chance Assistance Agreement

I,

, hereby voluntarily execute this Last Chance Assistance

Agreement (Agreement) with Baldwin County in compliance with the Baldwin County Personnel

Handbook (the Handbook).

I understand that, pursuant to the applicable provisions of the Handbook, my continuation as a

County employee is conditioned upon my signing this Agreement, upon a drug test conducted before

returning to work, upon the recommendation of the MRO and Personnel Director, and upon certification

by a physician or licensed counselor that I am able to perform the essential functions of my job.

By this Agreement, I represent that I have voluntarily submitted to the Counseling and/or

Rehabilitation for which I requested leave.

I acknowledge and reaffirm that I am now subject to drug testing, which may be required before I

return to work from leave and at any time(s) thereafter for a period of two years. This period of drug

testing shall not in any manner prevent or otherwise limit the County from the application of other drug

testing policies that may be applicable now and following the subject two-year period.

I acknowledge and agree that my violation of the Agreement shall be sufficient grounds for

termination.

/

Employee Signature /Date

State of Alabama )

County of Baldwin

)

I,

, a Notary Public in and for said County, in said State, hereby certify

that

, is the individual whose name is signed to the foregoing

Agreement, and who is known to me, acknowledged before me on this day that, being informed of the contents of

the Agreement, he/she executed the same voluntarily and personally.

Given under my hand and official seal, this the

day of , 20 .

SEAL

Notary Public

M

y Commission Expires: ___________________

VIII-21

Fill Online, Printable, Fillable, Blank VIII. Forms A. Application for Employment VIII-1 (Baldwin County Commission) Form

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Fillable VIII. Forms A. Application for Employment VIII-1 (Baldwin County Commission)

Fill Online, Printable, Fillable, Blank VIII. Forms A. Application for Employment VIII-1 (Baldwin County Commission) Form

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